J.37 CLIN 0004 Cost Proposal Template - Option Year 2 (PM, MIP, RAC) clean Amend 1.xlsx

XLSX spreadsheet 127 KB Posted Sep 4, 2020

Attached to: Part A/Part B Medicare Administrative Contractor (MAC) Jurisdiction L (JL)
Solicitation number: 75FCMC20R0008
Issued by: Department of Health and Human Services Centers for Medicare and Medicaid Services

About this file

Written by GovTribe AI · Dec 27, 2023

This is a cost proposal template and attachments for a Medicare Administrative Contractor solicitation. The Centers for Medicare and Medicaid Services is seeking proposals to administer Medicare Fee-For-Service claims processing and payment services for Jurisdiction L, which includes Delaware, Maryland, New Jersey, Pennsylvania, Washington D.C., and parts of Virginia. Offerors must submit cost proposals using the template and attachments, which include spreadsheets to provide pricing details by labor category, travel costs, subcontractors, other direct costs, and total costs for base period and option years. The template also includes sections for indirect costs, fees, and complementary credits. Proposals are due by the date specified in the solicitation to provide Medicare administrative support services for Jurisdiction L.

View the file

Other files

File	Type	Posted
J.23 Government Provided Proposal Assumptions (GPPA) redline Amend 2.docx	DOCX document	Sep 16, 2020
J.23 Government Provided Proposal Assumptions (GPPA) clean Amend 2.docx	DOCX document	Sep 16, 2020
75FCMC20R0008 Amend 2.pdf	PDF	Sep 16, 2020
JL Solicitation 75FCMC20R0008 Sections B-M CLEAN Amend 1.pdf	PDF	Sep 4, 2020
Q and A RFP 75FCMC20R00008.xlsx	XLSX spreadsheet	Sep 4, 2020
J.34 CLIN 0001 Cost Proposal Template - Implementation clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.23 Government Provided Proposal Assumptions (GPPA) redline Amend 1.docx	DOCX document	Sep 4, 2020
J.48 CLIN 0015 Cost Proposal Template - Option Year 5 (MPIP) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.43 CLIN 0010 Cost Proposal Template - Base Year (MPIP) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.22 Basis of Estimate redline Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.22.A Historic & Proposed FTE, Hours & Gross Cost Instructions & Narrative redline Amend 1.docx	DOCX document	Sep 4, 2020
J.46 CLIN 0013 Cost Proposal Template - Option Year 3 (MPIP) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.1 Statement of Work (SOW) clean Amend 1.docx	DOCX document	Sep 4, 2020
J.33 Cost Template Summary Sheet clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.21 Proposal Self-Check Tool clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.49 CLIN 0016 Cost Proposal Template - Option Year 6 (MPIP) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.22.A Historic & Proposed FTE, Hours & Gross Cost Instructions & Narrative clean Amend 1.docx	DOCX document	Sep 4, 2020
JL Solicitation 75FCMC20R0008 Sections B-M REDLINE Amend 1.pdf	PDF	Sep 4, 2020
J.45 CLIN 0012 Cost Proposal Template - Option Year 2 (MPIP) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.40 CLIN 0007 Cost Proposal Template - Option Year 5 (PM, MIP, RAC) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.41 CLIN 0008 Cost Proposal Template - Option Year 6 (PM, MIP, RAC) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.22 Basis of Estimate clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.38 CLIN 0005 Cost Proposal Template - Option Year 3 (PM, MIP, RAC) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.42 CLIN 0009 Cost Proposal Template - Outgoing Contractor Workload Transition Activities clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.36 CLIN 0003 Cost Proposal Template - Option Year 1 (PM, MIP, RAC) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.1 Statement of Work (SOW) redline Amend 1.docx	DOCX document	Sep 4, 2020
J.47 CLIN 0014 Cost Proposal Template - Option Year 4 (MPIP) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.35 CLIN 0002 Cost Proposal Template - Base Year (PM, MIP, RAC) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.23 Government Provided Proposal Assumptions (GPPA) clean Amend 1.docx	DOCX document	Sep 4, 2020
J.21 Proposal Self-Check Tool redline Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.39 CLIN 0006 Cost Proposal Template - Option Year 4 (PM, MIP, RAC) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
J.44 CLIN 0011 Cost Proposal Template - Option Year 1 (MPIP) clean Amend 1.xlsx	XLSX spreadsheet	Sep 4, 2020
75FCMC20R0008.pdf	PDF	Sep 4, 2020
J.37 CLIN 0004 Cost Proposal Template - Option Year 2 (PM, MIP, RAC).xlsx	XLSX spreadsheet	Aug 3, 2020
J.22.A Historic & Proposed FTE, Hours & Gross Cost Instructions & Narrative.docx	DOCX document	Aug 3, 2020
J.24 Attestations.docx	DOCX document	Aug 3, 2020
J.45 CLIN 0012 Cost Proposal Template - Option Year 2 (MPIP).xlsx	XLSX spreadsheet	Aug 3, 2020
J.10 Contractor Business Ethics COI and Compliance Program Requirements.docx	DOCX document	Aug 3, 2020
J.1.B List of Key Acronyms.docx	DOCX document	Aug 3, 2020
J.33 Cost Template Summary Sheet.xlsx	XLSX spreadsheet	Aug 3, 2020
J.35 CLIN 0002 Cost Proposal Template - Base Year (PM, MIP, RAC).xlsx	XLSX spreadsheet	Aug 3, 2020
J.23.A GPPA Audit & Reimbursement Tables.xlsx	XLSX spreadsheet	Aug 3, 2020
J.42 CLIN 0009 Cost Proposal Template - Outgoing Contractor Workload Transition Activites.xlsx	XLSX spreadsheet	Aug 3, 2020
J.2 Deliverable Schedule.docx	DOCX document	Aug 3, 2020
J.1 Statement of Work (SOW) - Jurisdiction L.docx	DOCX document	Aug 3, 2020
J.7 AB MAC Award Fee Plan and Self Assessment Template.docx	DOCX document	Aug 3, 2020
J.9 Non-Disclosure Statement.docx	DOCX document	Aug 3, 2020
J.40 CLIN 0007 Cost Proposal Template - Option Year 5 (PM, MIP, RAC).xlsx	XLSX spreadsheet	Aug 3, 2020
J.43 CLIN 0010 Cost Proposal Template - Base Year (MPIP).xlsx	XLSX spreadsheet	Aug 3, 2020
J.1.A List of Key Definitions.docx	DOCX document	Aug 3, 2020

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CLIN-0004 Consolidated SLIN

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.37

(Provide a cost spreadsheet for each CLIN proposed)

CLIN 0004 Consolidated

SLIN 0004AA (PM)

SLIN 0004AB (MIP)

SLIN 0004AC (RAC)

SLIN 0004AD (VA)

Reserved

SLIN 0004AL

A/B SERVICES

Total FTEs

Program Management (PM)

Medicare Integrity Program (MIP)

Support of Recovery Audit Program Operations

VA Remittance Advice Project (JH only)

Future Use

Records Storage and Retrieval Costs (J5 only)

GRAND TOTAL

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subtotal Direct Labor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0 $0.00

Total Direct Labor $0 $0 $0 $0 $0 $0 $0.00

Travel (See separate schedule. Total should match)		$0		$0		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs (See separate schedule. Total should match.) $0 $0 $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0 $0 $0.00

Base Fee (at ____%)	$0	$0	$0	$0	$0	$0	$0.00
Award Fee (at ______%)	$0	$0	$0	$0	$0	$0	$0.00
Fixed Fee (at ______%)	$0	$0	$0	$0	$0	$0	$0.00

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0 $0 $0.00

Complementary Credits	$0						$0.00
Note: Comp. credit information will be provided by CMS prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0	$0	$0	$0	$0.00

20190930

v2-10 20180824

75FCMC20R0008

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

CLIN-0004

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.37

(Provide a cost spreadsheet for each CLIN proposed)

CLIN 0004

SLIN 0004 PM A

SLIN 0004 MIP A

SLIN 0004 PM B

SLIN 0004 MIP B

SLIN 0004 RAC A

SLIN 0004 RAC B

SLIN 0004

SLIN 0004AL

A/B SERVICES

Total FTEs

Part A/Program Management (PM)

Part A/Medicare Integrity Program (MIP)

Part B/Program Management (PM)

Part B/Medicare Integrity Program (MIP)

Part A/Support of Recovery Audit Program Operations

Part B/Support of Recovery Audit Program Operations

Reserved

Records Storage and Retrieval Costs for Non-J5 Legacy A Records (J1, J4, J12) Jurisdiction 5 only

GRAND TOTAL

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS

Direct Labor
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subtotal Direct Labor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Total Direct Labor $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Travel (See separate schedule. Total should match)		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs (See separate schedule. Total should match.) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Base Fee (at ____%)	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0.00
Award Fee (at ______%)	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0.00
Fixed Fee (at ______%)	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0.00

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Complementary Credits	$0		$0								$0.00
Note: Comp. credit information will be provided by CMS prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0.00
v.1.58 05042016

75FCMC20R0008

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

TRAVEL

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.37

TRAVEL SUMMARY

CLIN 0004

	Purpose of Trip	SOW WBS
Crosswalk	Labor Category Taking Trip	Trip Origin	Destination	# People
(A)	# Trips
(B)	# Days
(C)	# Nights
(D)	Lodging Rate
(E)	Lodging
(F=EDA)	M&IE
(G)	Total Lodging

and M&IE

(H=F+G)	Airfare
(I)	Car Rental
(J)	Misc
(K)	Local

Mileage

(L)	Total Per Trip
(M=H+I+J+K+L)	Total For All Trips

(N=M*B )

	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
	$ -	$ -		$ -	$ -
			TOTAL TRAVEL		$ -
Travel Assumptions:

75FCMC20R0008

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

ODC

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.37

(Provide an ODC Spreadsheet for each CLIN Proposed)
CLIN 0004 A/B SERVICES	SLIN 0004 PM A	SLIN 0004 MIP A	SLIN 0004 PM B	SLIN 0004 MIP B	SLIN 0004 RAC A	SLIN 0004 RAC B	SLIN 0004 VA A	SLIN 0004 VA B	SLIN 0004 Reserved	SLIN 0004AL Rec. Storage	GRAND
Cost Element	Amount	Amount	Amount	Amount	Amount	Amount	Amount	Amount	Amount	Amount	TOTAL
											$0.00
Add costs by category											$0.00
											$0.00
											$0.00
											$0.00
											$0.00
											$0.00
											$0.00
TOTAL ODCs	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00

75FCMC20R0008

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

SLIN-0004 PM A

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.37

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004 PM A

C.1.4.4

C.5.3

C.5.4

C.5.5

C.5.7

C.5.8

C.5.9

C.5.10

C.5.11

C.5.23

C.5.27

C.6

C.7

A/B SERVICES

Total FTEs

Total FTE Hours

Home Health and Hospice Requirements

Infrastructure Requirements

Administrative Requirements

Provider Enrollment

Provider Customer Service Program

Claims Processing

Reopenings of Medicare Initial Claims Determinations

Appeals of Medicare Initial Claims Determinations

FM of Trust Fund Dollars

Program Management Office

Support & Coordination with SMRC Operations

Interface Requirements

Jurisdiction Specific Requirements

CREDITS

AWARD FEE

GRAND TOTAL

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS
Direct Labor
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0.00	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Total Direct Labor $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Travel		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Base Fee (at ____%)	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0		$0.00
Award Fee (at ______%)														$0	$0.00
Fixed Fee (at ______%)	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0		$0.00

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Complementary Credits																$0		$0.00
Note: Comp. credit information will be provided by CMS prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	0.00	0.00	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0.00

75FCMC20R0008

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

SLIN-0004 MIP A

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.37

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004 MIP A

C.1.4.4

C.5.6

C.5.7

C.5.11

C.5.12

C.5.13

C.5.14

C.5.15

C.6

C.7

A/B SERVICES

Total FTEs

Total FTE Hours

Home Health and Hospice Requirements

LCDs

Provider Customer Service Program

FM of Trust Fund Dollars

Medical Review

Coordination with PSCs/ZPICs

MSP

Provider Oversight

Interface Requirements

Jurisdiction Specific Requirements

AWARD FEE

GRAND TOTAL

Medicare Integrity Program

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS
Direct Labor
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0.00	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Total Direct Labor $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Travel		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Base Fee (at ____%)	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0		$0.00
Award Fee (at ______%)											$0	$0.00
Fixed Fee (at ______%)	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0		$0.00

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Complementary Credits
Note: Comp. credit information will be provided by CMS prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	0.00	0.00	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0.00

75FCMC20R0008

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

SLIN-0004 PM B

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.37

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004 PM B

C.5.3

C.5.4

C.5.5

C.5.7

C.5.8

C.5.9

C.5.10

C.5.11

C.5.23

C.5.27

C.6

C.7

A/B SERVICES

Total FTEs

Total FTE Hours

Infrastructure

Administrative Requirements

Provider Enrollment

Provider Customer Service Program

Claims Processing

Reopenings of Medicare Initial Claims Determinations

Appeals of Medicare Initial Claims Determinations

FM of Trust Fund Dollars

Program Management Office

Support & Coordination with SMRC Operations

Interface Requirements

Jurisdiction Specific Requirements

CREDITS

AWARD FEE

GRAND TOTAL

Program Management

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS
Direct Labor
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0.00	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Total Direct Labor $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Travel		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Base Fee (at ____%)	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0		$0.00
Award Fee (at ______%)													$0	$0.00
Fixed Fee (at ______%)	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0		$0.00

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Complementary Credits															$0		$0.00
Note: Comp. credit information will be provided by CMS prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	0.00	0.00	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0.00
V1.3 04092012

75FCMC20R0008

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

SLIN-0004 MIP B

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.37

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004 MIP B

C.5.6

C.5.7

C.5.12

C.5.13

C.5.14

C.5.15

C.6

C.7

A/B SERVICES

Total FTEs

Total FTE Hours

LCDs

Provider Customer Service Program

Medical Review

Coordination with PSCs/ZPICs

MSP

Provider Oversight

Interface Requirements

Jurisdiction Specific Requirements

AWARD FEE

GRAND TOTAL

Medicare Integrity Program

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS
Direct Labor
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
		0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0.00	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Total Direct Labor $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Travel		$0		$0		$0		$0		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0 $0 $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Base Fee (at ____%)	$0	$0	$0	$0	$0	$0	$0	$0		$0.00
Award Fee (at ______%)									$0	$0.00
Fixed Fee (at ______%)	$0	$0	$0	$0	$0	$0	$0	$0		$0.00

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0 $0 $0 $0 $0 $0.00

Complementary Credits
Note: Comp. credit information will be provided by CMS prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	0.00	0.00	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0.00

75FCMC20R0008

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

SLIN-0004 RAC A

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.37

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004 RAC A

C.5.26.1

C.5.26.2

C.5.26.3

C.5.26.4

C.5.26.5

Reserved

A/B SERVICES

Total FTEs

Adjustment of Recovery Auditor Selected Claims

Handling Underpayments and Overpayments Identified by the Recovery Auditor

Appeals of Recovery Auditor Adjusted Claims

Reporting for Recovery Audit Program Support Operations

Other Recovery Audit Program Support Activities

Future Use

AWARD FEE

GRAND TOTAL

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS
Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0.00

Total Direct Labor $0 $0 $0 $0 $0 $0.00

Travel		$0		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0 $0.00

Base Fee (at ____%)	$0	$0	$0	$0	$0		$0.00
Award Fee (at ______%)						$0	$0.00
Fixed Fee (at ______%)	$0	$0	$0	$0	$0		$0.00

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0 $0 $0.00

Complementary Credits
Note: Comp. credit information will be provided by CMS prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0	$0	$0	$0	$0	$0	$0.00

75FCMC20R0008

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

SLIN-0004 RAC B

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.37

(Provide a cost spreadsheet for each CLIN proposed)

SLIN 0004 RAC B

C.5.26.1

C.5.26.2

C.5.26.3

C.5.26.4

C.5.26.5

Reserved

A/B SERVICES

Total FTEs

Adjustment of Recovery Auditor Selected Claims

Handling Underpayments and Overpayments Identified by the Recovery Auditor

Appeals of Recovery Auditor Adjusted Claims

Reporting for Recovery Audit Program Support Operations

Other Recovery Audit Program Support Activities

Future Use

AWARD FEE

GRAND TOTAL

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Rates

Total

Hours

Total

COST ELEMENTS
Direct Labor
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00	$0	0	$0.00
Subtotal Direct Labor	0		$0	0		$0	0		$0	0		$0	0		$0	0	$0.00

Fringe Benefits (at ____%) $0 $0 $0 $0 $0 $0.00

Total Direct Labor $0 $0 $0 $0 $0 $0.00

Travel		$0		$0		$0		$0		$0		$0.00
SUBCONTRACTORS
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Subcontractor Name	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00
Total Subcontractor	0	$0	0	$0	0	$0	0	$0	0	$0	0	$0.00

Other Direct Costs $0 $0 $0 $0 $0 $0.00

SUBTOTAL ALL DIRECT COSTS $0 $0 $0 $0 $0 $0.00

Indirect Costs (at ______ %) $0 $0 $0 $0 $0 $0.00

TOTAL OTHER BEFORE FEE $0 $0 $0 $0 $0 $0.00

Base Fee (at ____%)	$0	$0	$0	$0	$0		$0.00
Award Fee (at ______%)						$0	$0.00
Fixed Fee (at ______%)	$0	$0	$0	$0	$0		$0.00

TOTAL OTHER AFTER FEE $0 $0 $0 $0 $0 $0 $0.00

Complementary Credits
Note: Comp. credit information will be provided by CMS prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0	$0	$0	$0	$0	$0	$0	$0.00

75FCMC20R0008

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

SLIN-0004

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.37

(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0004		Resesrved
A/B SERVICES	Total FTEs	Future Use
		Hours	Rates	Total
COST ELEMENTS

Direct Labor
	0	$0.00	$0
	0	$0.00	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
Subtotal Direct Labor	0		$0

Fringe Benefits (at ____%) $0

Total Direct Labor $0

Travel		$0
SUBCONTRACTORS
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Total Subcontractor	0	$0

Other Direct Costs $0

TOTAL ALL DIRECT COSTS $0

Indirect Costs (at ______ %) $0

TOTAL OTHER BEFORE FEE $0

Base Fee (at ____%)	$0
Award Fee (at ______%)	$0
Fixed Fee (at ______%)	$0

TOTAL OTHER AFTER FEE $0

Complementary Credits
Note: Comp. credit information will be provided by CMS prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0

75FCMC20R0008

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

SLIN-0004AL

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.37

(Provide a cost spreadsheet for each CLIN proposed)
SLIN 0004AL - C.7.34		C.7.34
A/B SERVICES	Total FTEs	Records Storage and Retrieval Costs for non-J5 Legacy A Records (J1, J4, J12) (Jurisdiction 5 only)
		Hours	Rates	Total
COST ELEMENTS

Direct Labor
	0	$0.00	$0
	0	$0.00	$0
Add Other Appropriate Labor Categories (note: labor categories should match WBS)	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
	0	$0.00	$0
Subtotal Direct Labor	0		$0

Fringe Benefits (at ____%) $0

Total Direct Labor $0

Travel		$0
SUBCONTRACTORS
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Subcontractor Name	0	$0
Total Subcontractor	0	$0

Other Direct Costs $0

TOTAL ALL DIRECT COSTS $0

Indirect Costs (at ______ %) $0

TOTAL OTHER BEFORE FEE $0

Base Fee (at ____%)	$0
Award Fee (at ______%)	$0
Fixed Fee (at ______%)	$0

TOTAL OTHER AFTER FEE $0

Complementary Credits
Note: Comp. credit information will be provided by CMS prior to final proposal revision. Offerors should not propose amounts at this time.
GRAND TOTAL	$0

75FCMC20R0008

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

Confidential Procurement Sensitive

Reserved

RFP # 75FCMC20R0008

COST TEMPLATE - Attachment J.37

RFX-CMS-20XX-000X

PART A & PART B (A/B) MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

SLIN = Sub Line Item Number

Attachment J-XX &P v.1 consol 07/05/2016

File details come from the government source that posted it. Updated Sep 4, 2020.